Amnesteem 10mg/1 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK (3 BLISTER PACK in 1 CARTO ) (NDC: 00378661193)
2015 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
Plan Name |
Monthly Prem. |
De- duct- ible |
Does Plan Offer Additional Gap Coverage |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Plan’s Avg. Retail Drug Price 30-Day |
Tier Nbr. |
Tier Desc. |
30-Day Prfrd. Pharm |
90-Day Mail Order |
AARP MedicareComplete Plan 1 (HMO)
|
$0.00 |
$245 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $310.85 |
Browse Plan Formulary |
Affinity Medicare Passport Essentials (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $420.23 |
Browse Plan Formulary |
AgeWell New York FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $428.47 |
Browse Plan Formulary |
CenterLight Healthcare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $707.96 |
Browse Plan Formulary |
EmblemHealth Dual Assurance FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $485.91 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Empire Dual Advantage (HMO SNP)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$31.00 | $93.00 | None | $465.59 |
Browse Plan Formulary |
Fidelis Fully Integrated Dual Advantage (FIDA) (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | n/a | None | $532.00 |
Browse Plan Formulary |
GuildNet Gold Plus FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $485.91 |
Browse Plan Formulary |
Healthfirst AbsoluteCare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $500.06 |
Browse Plan Formulary |
RiverSpring FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | None | $931.83 |
Browse Plan Formulary |
Touchstone Health Medicare Freedom (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $421.75 |
Browse Plan Formulary |
|
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Touchstone Health Medicare Power (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $421.75 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
|
$0.00 |
$225 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $295.42 |
Browse Plan Formulary |
WellCare Advocate Complete FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
0% | 0% | None | $467.84 |
Browse Plan Formulary |
Fidelis Long Term Care Advantage (HMO SNP)
|
$3.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $532.00 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$28.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$69.00 | $172.50 | None | $485.99 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$30.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $282.63 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
LiveWell (HMO)
|
$32.90 |
$250 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $428.47 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$35.40 |
$320 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$21.00 | $42.00 | None | $532.00 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO SNP)
|
$36.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $500.06 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
|
$36.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $500.06 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $420.23 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $420.23 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
ArchCare Advantage (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $472.59 |
Browse Plan Formulary |
BeWell (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $428.47 |
Browse Plan Formulary |
CareWell (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $428.47 |
Browse Plan Formulary |
CenterLight Healthcare Direct Complete Plan (HMO SNP)
|
$36.90 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$7.25 | $21.75 | None | $707.96 |
Browse Plan Formulary |
EmblemHealth Dual Eligible (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$9.00 | $27.00 | None | $485.91 |
Browse Plan Formulary |
EmblemHealth Dual Eligible (PPO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$9.00 | $27.00 | None | $485.91 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
EmblemHealth MLTC PLUS (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$9.00 | $27.00 | None | $485.91 |
Browse Plan Formulary |
FeelWell (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $428.47 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$36.90 |
$240* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$15.00 | $30.00 | None | $532.00 |
Browse Plan Formulary |
Touchstone Health Medicare Grand (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $421.75 |
Browse Plan Formulary |
Touchstone Health Medicare Prestige (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $421.75 |
Browse Plan Formulary |
Touchstone Health Medicare Total (HMO)
|
$36.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None | $421.75 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Affinity Medicare Passport Select (HMO)
|
$46.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $420.23 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$69.00 |
$240 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $310.85 |
Browse Plan Formulary |
Empire MediBlue Select (HMO)
|
$69.00 |
$273 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $472.63 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$94.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | P | $513.05 |
Browse Plan Formulary |
GoldValue with Part D (HMO-POS)
|
$103.60 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $400.28 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$122.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $448.86 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
EmblemHealth Essential (HMO)
|
$122.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $448.08 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$122.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $512.15 |
Browse Plan Formulary |
Affinity Medicare Passport Elite (HMO)
|
$126.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None | $420.23 |
Browse Plan Formulary |
Preferred Gold with Part D (HMO-POS)
|
$167.40 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $400.28 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$173.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $448.86 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$173.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $448.08 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
EmblemHealth VIP (HMO)
|
$173.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $512.15 |
Browse Plan Formulary |
EmblemHealth Advantage (PPO)
|
$199.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $448.86 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$328.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $512.15 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$328.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $448.86 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$328.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $448.08 |
Browse Plan Formulary |